Progress in Additive Manufacturing (2021) 6:19–37

https://doi.org/10.1007/s40964-020-00159-x

REVIEW ARTICLE

The role of 3D printing during COVID‑19 pandemic: a review

Guilherme Arthur Longhitano1   · Guilherme Bitencourt Nunes1 · Geovany Candido1 · Jorge Vicente Lopes da Silva1

Received: 22 July 2020 / Accepted: 7 November 2020 / Published online: 24 November 2020
© Springer Nature Switzerland AG 2020

Abstract
The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus-2 (SARS-
CoV-2), has spread through more than 180 countries, leading to diverse health systems overload around the world. Because
of the high number of patients and the supply chain disruption, it generated a shortage of medical devices and personal
protective equipment. In this context, initiatives from the additive manufacturing community emerged to fight the lack of
devices. Diverse designs were produced and are currently being used in hospitals by patients and health workers. However,
as some devices must follow strict standards, these products may not fulfill these standards. Therefore, to ensure the user’s
health, there is a need for understanding each device, their usage, and standards. This study reviews the use of additive manu-
facturing during COVID-19 pandemic. It gathers the source of several 3D printed devices such as face shields, face masks,
valves, nasopharyngeal swabs, and others, discussing their use and regulatory issues. In this regard, the major drawbacks of
the technology, addressed for the next pandemic scenario, are highlighted. Finally, some insights of the future of additive
manufacturing during emergency are given and discussed.

Keywords  Additive manufacturing · 3D printing · COVID-19 · Pandemic · PPE · Medical devices

1 Introduction
The coronavirus disease 2019 (COVID-19) had its first doc-
umented patient in December 2019, Wuhan, China [1]. Since
then, the virus has spread through the world, and the World
Health Organization (WHO) defined the disease as pan-
demic in 11 March 2020 [2]. Just 9 months after identified
“patient zero”, the disease has spread, on October 9th, in 188
countries and regions with more than 36.6 million confirmed
cases and more than 1,063,000 global deaths according to
the official data of the countries in the COVID-19 Dash-
board by the Center for Systems Science and Engineering
(CSSE) at Johns Hopkins University (JHU) [3].
The severe acute respiratory syndrome coronavirus-2
(SARS-CoV-2) can be transmitted though droplets [4],
aerosol, and direct and indirect physical contact through
contaminated surfaces, in which the virus may remain up
to 72 h [4, 5]. Regarding the transmission modes involv-
ing droplets and aerosol, they are still under research and a
* Guilherme Arthur Longhitano
guilonghita@gmail.com
1
Center for Information Technology Renato Archer (CTI),
Campinas, Brazil
consensus has not been reached [6, 7]. Some recent works
point out that aerosol transmission may be more significant
than previously considered [8, 9].
Infected people might be asymptomatic [10, 11], but may
also present severe acute respiratory syndrome (SARS),
resulting in intensive care unit (ICU) admission [11, 12].
These are all factors that contribute to the virus spread
ratio, leading to health systems overload around the world.
The high number of patients created a supply chain disrup-
tion, generating a shortage of personal protection equipment
(PPE) and medical devices in hospitals for fighting off the
virus.
To fight the lack of devices and equipment, companies,
universities, independent groups, and individuals started a
movement of production of diverse items to supply hospitals
and people that are facing the shortage [13]. Various devices
have been produced, such as face masks, face shields, test
swabs, door handle attachments, valves [13–17] etc. and are
being massively shared by social media [18, 19]. In this con-
text, additive manufacturing (AM), commonly named as 3D
printing, has emerged as one remarkable fabrication process
because of its accessibility and flexibility to quickly produce
complex and monolithic parts or even mechanical systems
[20–22]. Another reason is that people involved with AM

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are open-mind, creative, with interdisciplinary relationships
and applications. Therefore, AM technology allows the
user to easily produce parts directly from a STL file format
(designed in a CAD system), which can be easily found and
shared in makers hubs or even at social media [19]. Finally,
during the last decade, because of patent period expiration,
desktop 3D printers have become accessible as low-end-
machines for common people by open access projects that
dramatically reduced their costs [22, 23] and the entrance
barriers for low range AM equipment.
However, 3D printed parts may present different proper-
ties and finishes because of differences of materials used,
technology, and individual machine software and calibra-
tion, even for a same STL project [24]. As PPE and medi-
cal devices must follow strict standards, these do it yourself
(DIY) products may not fulfill the requirements of these
standards, representing a risk to the users’ health. Therefore,
there is a need for understanding each device, usage, and
standards to ensure that these products can in fact be helpful
for the purpose intended with the lowest risk for patients and
healthcare personal.
This study aims at reviewing the use of additive manu-
facturing during COVID-19 pandemic. It focuses on vari-
ous PPE, medical devices, and other applications, providing
their source and discussing their use and regulatory topics.
Finally, a perspective for the future of AM during emergency
situations is given.
2 Additive manufacturing
As defined by ISO/ASTM 52900 standard [25], additive
manufacturing is a “process of joining materials to make
parts from 3D model data, usually layer upon layer, as
opposed to subtractive manufacturing and formative manu-
facturing methodologies”. The 3D printing terminology is
commonly associated with machines that are low end in
price and/or overall capability [25].
The first commercial system of AM dates from the year
1987 and consists of the stereolithography (SLA) technique,
which uses photo-curable polymers [20, 21]. Nowadays, a
wide range of techniques and materials are available in AM
technologies. The International Standard ISO/ASTM 52900
[25] divides AM processes in seven different categories: vat
photopolymerization, material extrusion, material jetting,
binder jetting, powder bed fusion, sheets addition, and direct
energy deposition. These processes use polymers, ceramics,
metals, and composites as feedstocks to build a part [20,
21, 25, 26]. Some techniques available on market are SLA,
fused deposition modeling (FDM), fused filament fabrica-
tion (FFF), PolyJet, direct light projection (DLP), multi jet
fusion (MJF), selective laser sintering (SLS), selective laser
melting (SLM), and electron beam melting (EBM).
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Progress in Additive Manufacturing (2021) 6:19–37
Because of its wide range of materials and techniques,
AM can be used in a myriad of areas and applications,
from rapid prototyping to medicine and aerospace end-use
parts [20, 27]. The direct-from-CAD production, freedom
of design, ease of customization, low number of steps, and
rapid production of unique or small batches of parts are
some of the main advantages of AM [20, 22, 27, 28]. How-
ever, there are a few common drawbacks for AM techniques
that are still present, like parts anisotropy [20], high cost of
industrial equipment, high cost of feedstocks (when com-
pared to traditional techniques) [21], and high cost for big
batches [22, 28]. Another serious concern still present in
AM is the repeatability among machines of the same brand
and models and even between consecutives processes [20].
3 Pandemic and additive manufacturing
At the same time that the COVID-19 pandemic increased
the demand for medical devices and created a new market of
products for general public, it provoked various supply chain
disruptions, rapidly generating a shortage of many critical
items, such as PPE [14, 16, 29–31]. Following this issue,
companies, groups and individuals started to cooperate to
supply people and hospitals that are facing items shortage
[14, 24, 28, 32, 33]. In this regard, AM has emerged as a
potential flexible solution for locally supplying various types
of these items, demonstrating the potential of AM for a local
and flexible production of strategic items, reducing supply
chain dependency [13, 27, 34].
One of the main reasons that made AM an important tool
during the pandemic is the great number of users around the
world [19], many of them very specialized, innovative and
creative. During the last decade, the decrease in the cost
of processors and the expiration of patents made desktop
3D printers as low-end-machines [22, 23]. Furthermore, the
feedstock price, mainly filament polymers, for these printers
are in constant lowering [22]. Thus, the ability to produce
parts for supplying the pandemic shortage is not exclusive
for industry: makers, people who own or have access to rapid
manufacturing machines such as 3D printers, have been
proven to significantly contribute during the disease [23].
A second reason is that people who have a 3D printer
do not require CAD-design knowledge to produce parts.
3D printable files can be easily found in internet via 3D
printing open-design repositories, makers hubs or even at
social media [19], only requiring a desktop printer to start
production.
A third reason is that complex parts that would require
a long period of time of manufacturing planning via tradi-
tional processes can be quickly put into production by AM.
It has a minimal lead time to deliver small batches of parts,
producing an almost immediate response to the crisis [22,
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28, 35]. Consequently, when media started to share informa-
tion on shortage of items, people could start helping as soon
as they had STL files. The technique ability for rapid proto-
typing also allowed the fast production of the first designs
and machine prototypes. Furthermore, an AM facility for
low-end machines does not require complex planning or
infrastructure. As example, François et al. [36] presented
a technical note on the production of devices related to the
COVID-19 pandemic for Greater Paris University Hospitals
and various state institutions. They reported that 60 FFF
machines were ordered, delivered, and settled in a period of
4 days. Therefore, if there is an urgent demand of emergency
items, a 3D printer facility can be quickly installed and put
into work. Using a single desktop 3D printer, Thomas et al.
[37] took 21 days from conception to delivery of 50 reusable
personalized face masks based on the Stopgap surgical face
mask design [38].
4 Data sharing
One of the main advantages of AM is the direct-from-CAD
production. The user can easily produce parts from CAD
files, which can be designed or obtained from internet
specialized repositories. Currently, there are various file
repositories like Thingiverse [39], NIH 3D Print Exchange
[40], GrabCAD [41], Pinshape [42], Cults [43], Yeggi [44],
MyMiniFactory [45] and others. These websites store 3D
printable files, usually in STL file format, which are shared
by users. These repositories allow the upload, download,
exchange, and even edition and new upload of 3D printing
files and information by anyone.
During the pandemic, data sharing has rapidly increased
to spread initiatives and solutions as an attempt to fight off
the virus. From this perspective, social media [19, 33], com-
pany websites [46, 47] and file repositories have played a
main role in sharing data [23, 33, 35]. As social distancing
was the main strategy for most governments to reduce trans-
mission rates, people at homework increased social media
use [19]. After the virus was announced by China, a wave of
information sharing occurred though social media as never
seen before. Unfortunately, part of these were unreliable
information like conspiracy theories or misleading rumors,
generating panic and depletion of stockpiles [48]. How-
ever, social media also played a role in sharing initiatives
aiming at providing PPE and medical devices for people in
need [18, 19, 49]. In line with social media, file repositories
websites were used for sharing downloadable CAD files for
3D printing parts to be used during the pandemic [19, 49].
Furthermore, there are several websites hosting platforms
like github and gitlab, dedicated to open projects related to
COVID-19. These platforms facilitate quick design inter-
action among different professionals by allowing access to
anyone interested to contribute and share their developments
[50]. Global network put together volunteers and experts via
dedicated hubs to provide diverse types of products to supply
the community [28]. These interactions, associated with the
use of desktop 3D printers, act as an iteration chain process
for optimizing the project and reaching a final design in a
short period of time.
In addition, various companies worked on more engi-
neered and reliable data and designs solutions using 3D
printing workforce around the world. Some examples of
notable projects, just to cite a few, are ISINNOVA’s valves
[51, 52], Prusa’s face shields [53] and Materialise’s [46]
solutions for non-contact tools and masks. Furthermore,
there are projects like the Open Source Medical Supplies
that gathered together multidisciplinary professionals, such
as engineers, medical professionals, makers, researchers etc.
to lead and inform people who are trying to fight the equip-
ment shortage [54]. Finally, scientific papers [12, 50, 55,
56] were also used as a way of data and information sharing.
In this case, more detailed data in fabrication methods and
results are given, as well as more reliable data because of the
peer-reviewing process. However, they are less accessible
to common public since they can be found only in specific
scientific media and some publications are not open access.
5 3D printed devices
The following sections present and discuss diverse types
of solutions produced by AM during COVID-19 pandemic.
5.1 Personal protective equipment—PPE
PPE are the most printed devices during the pandemic
because of their relative simplicity, low geometrical toler-
ance requirements and lower-risk classification within Food
and Drug Administration (FDA) or other regulatory bodies,
when compared more complex devices like ventilators and
valves [23].
Face shields constitute majority of the projects among
PPE [23, 57]. FDA considers face shields as Class I medi-
cal devices [4, 58], and WHO considers them as an alter-
native to medical masks during shortages [59]. They are
a head-worn frame with a clear plastic sheet to protect
the user’s face from direct contamination via sprays and
splashes [4, 13, 23, 60]. Another requirements are that
they must be easy to disinfect, comfortable during long
periods, durable and allow additional PPE wearing [61]. It
is important to remark that in highly infectious situations
the face shield must be used with additional PPE equip-
ment [4, 61]. The frame consists of a simple geometry
that can easily be 3D printed [53, 56, 61, 62]. A further
approach uses SLA to produce a hollow frame to be used
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with an external airflow, defogging the visor and prevent-
ing ambient air from entering [63]. The plastic sheet is
cut manually, using scissors and an office puncher [56], or
automatically, using laser cutters [60]. Some material of
choice are polycarbonate, Propionate, acetate, polyvinyl
chloride, and polyethylene terephthalate glycol (PETG)
[60]. An elastic band may be suitable in some models [61,
64]. The face shield design must cover the sides of the
face and below the chin [59]. Printing time and price of
face shields are design, machine, material, and parameters
dependents [4, 56, 57]. Figure 1 shows diverse 3D printed
face shields models built using different AM techniques
and materials. Designs of face shields can be found in
various file repositories [39, 40, 42, 43, 45].
Safety goggles act in a similar way of face shields: they
work as a physical barrier for the eyes. Eye protection is
indicated as a protection from infected patients’ exhaled
droplets [10]. Farsoon, Huaxiang and LEHVOSS companies
designed, validated, and made available for download two
sizes of safety googles to be made by SLS, SLA or FFF tech-
nologies. The lens are to be cut separately in acrylic material
[65]. There are other available models, such as PUC-Rio’s
Fig. 1  Various face shields designs made by different AM techniques.
a Hígia model [62]—SLS/PA12; b Prusa RC1 model [53]—SLS/
PA12; c Prusa RC2 model [53]—FDM/ABS; d adapted Prusa model
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Progress in Additive Manufacturing (2021) 6:19–37
[66], FRC Team’s [67] and Creality’s [68] designs. However,
there is no information if these models were validated.
N95 respirators (class II device by FDA [58]) and surgical
masks (class I device by FDA [58]) are critical PPE. Both
are recommended by the WHO for health workers during
this pandemic [59], and are intended to filter particles of
bacteria and virus to avoid contamination [31]. N95 respira-
tors have a minimum efficiency reporting value (MERV) of
95% for particles larger than 0.3 µm [32, 69]. Even though
COVID-19 virus particle size are under 0.16 µm [1, 70],
these respirators are capable of filtering droplets that work as
vehicles of virus transportation [32]. Surgical masks cannot
assure the same protection as a N95 respirators [64, 69], but
they can provide significant reduction, leading various coun-
tries and states to incentive or obligate people to use even
homemade fabric masks to reduce contamination ratio [59].
Because of the critical function and high demand, diverse
3D printable projects and designs were proposed. 3D printed
adaptor valves to be connected with full-face snorkeling
masks and a high-efficiency particulate air (HEPA) filter
(Fig. 2) were suggested for health workers usage [49, 71,
72]. These full-face snorkel masks have three diaphragm
1—SLS/PA12; adapted Prusa model 2—FDM/PC; adapted Prusa
model 3—FDM/PC. Face shields assembly with a Prusa RC1 model
and b adapted Prusa model 3
Progress in Additive Manufacturing (2021) 6:19–37 23
Fig. 2  a Different versions of valve adaptors made using SLS/PA12
and FDM/PC. b PPE mask assembly with snorkeling mask, adaptor
and HEPA filter
valves and airways that ensure the air inlet only through the
HEPA filter and prevents the visor from fogging. In a study
made by Kroo et al. [71], this PPE exceeded the standards
of N95 respirators. However, in a study made by Gierthm-
uehlen et al. [73], the full-face snorkel mask obtained only a
85% filtering efficiency for 580–660 nm particle size, which
is below the N95 filters efficacy. These conflicting results
raise the need for more tests to reach a definitive conclusion.
Another approach for PPE is the production of open-
source powered air-purifying respirators (PAPR), classified
as class II devices by FDA [58]. In this case, AM is being
used for producing parts of the mask and the pump for the
equipment assembly [74] or reposition parts [75]. Further-
more, Erickson et al. [76] proposed 3D printing manifolds to
adapt surgical helmet systems as PPE during the pandemic
since these systems are going unused because of elective
surgeries delay.
A simpler approach, which acts as a substitute to surgical
masks and does not require prefabricated masks is 3D prints,
a half-face mask, and uses diverse materials such as filters
in an air inlet/outlet. The mask efficiency will depend on the
AM technique used, the print quality, the user’s anatomy,
and the filter material used [77]. Tino et al. [15] reviewed
five different types of half-face masks made by FFF and
found out some models are inviable by long printing time
or inefficient sealing. Swennen, Pottel and Haers [77] pre-
sented a proof of concept of a 3D printed mask composed by
two reusable components made by SLS and two disposable
components (head band and filter membrane). They pro-
pose using 3D facial scanning software from smartphones
to obtain a 3D model of the user’s anatomy to improve the
mask fit.
It is important to remark that these masks require reg-
ulatory approval [14, 15]. Nevertheless, a collaboration
between the NIH 3D Print Exchange website, FDA, the
Veterans Healthcare Administration, and America Makes
in 3D printing solutions inform which models undergone
review in a clinical setting and were found appropriate when
fabricated with the specified parameters [40]. One reviewed
and validated model is the Stopgap surgical face mask [38],
to be fabricated via SLS or MJF, shown in Fig. 3a and b. It
consists of two sterilizable 3D printed components, elastic
straps, and a filter material, which must be disposed after
each use. However, a preprinted work by Bezek et al. [78]
tested the Stopgap [38], La Factoria 3D COVID-19 [79] and
Montana face masks [80] made by powder bed fusion indus-
trial and FFF industrial and desktop equipment. In almost
all cases, masks without post-processing steps presented an
overall filtering efficiency under 60% for particles between
100 and 300 nm, which is comparable to fabric masks. The
only exception was the Montana design made in ULTEM
material using an industrial FFF printer, which presented a
90–95% efficiency. Further, they showed that post-process-
ing steps can improve the masks filtering efficiency. Their
work indicates the need for further quantitative testing and
validation of 3D printed PPE and for development and stand-
ardization of post-processing steps to improve the masks
efficiency. In agreement with the previous work, Gierthmue-
hlen et al. [73] obtained a filtering efficacy of only 39% for
La Factoria’s mask model, which is a home-made vacuum
cleaner bag mask model (70%). They highlight that a tight
fit is essential for the masks to perform optimally.
Finally, there are parts that were designed to be used
as support to PPE. N95 or surgical masks are critical and
required PPE for healthcare professionals [59]. Because of
the long shifts, the delicate skin behind the ears starts to
breakdown by the contact with the mask bands. 3D printed
ear savers, or mask extenders [35], were designed to improve
the wellness of health workers and people who work for long
periods with face masks. In the NIH 3D Print Exchange
repository [40], there are various reviewed models such
as the one submitted by tech4primary user [81], shown in
Fig. 3c and d. Additionally, to improve the fit of surgical
masks, Bellus3D designed a face mask fitter (Fig. 3e and f),
based on a 3D printed plastic frame [82]. The design uses the
company’s face scan software (for smartphones) for creating
an adapted geometry to the user’s face.
5.2 Valves
COVID-19 patients may present SARS, with high respira-
tory rates and low oxygen levels [83]. Patients with these
critical hypoxemic symptoms are normally submitted to
invasive mechanical ventilation (IMV) procedure [84]. Dur-
ing this procedure, droplets and aerosols from the patient are
released, creating a propitious environment for contamina-
tion of health workers [83, 85–87]. In these cases, patients
remain in induced coma for long periods of time, increasing
the risk of death using sedatives and the occupation of inten-
sive care unit (ICU) beds. These are critical facts during the
COVID-19 pandemic because of the shortage of ICU beds,
mechanical ventilators, and high risk of contamination for
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Fig. 3  Face mask and support
parts made by SLS/PA12. a
Stopgap surgical face mask
[38] b Ear saver designed by
tech4primary user from NIH 3D
Print Exchange [81]. c Face fit-
ter designed by Bellus3D [82]
health workers. A possible way for reducing intubation is
using non-invasive ventilation (NIV) procedures, such as
continuous positive airways pressure (CPAP). The WHO
recommends the use of NIV as a first approach before intu-
bation of patients [10]. Wang et al. [88] made a study in
which 27 COVID-19 patients presenting SARS were submit-
ted to NIV. From these patients, only 4 had to be intubated.
However, because COVID-19 can be transmitted through
aerosols and droplets [4, 14], NIV with inappropriate seals
should not be used [87, 89]. Hence, exhaled air from the
patients submitted to NIV cannot be returned to the environ-
ment or must be filtered with a HEPA filter.
Italian ISINNOVA company created a solution using 3D
printing connector valves to be used with Decathlon’s Sur-
face Snorkeling Mask Easybreath® as full-face masks for
CPAP procedure (Fig. 4c). The valves, named as Charlotte
(Fig. 4a) and Dave (Fig. 4d), can be downloaded at ISIN-
NOVA’s website. FFF/polylactic acid (PLA) are the recom-
mended fabrication method/material [51]. This assembly
can be used with an oxygen flow or mechanical ventilator,
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Progress in Additive Manufacturing (2021) 6:19–37
may minimize environment contamination [12], and can be
sterilized and reused [32].
Another approach related to the shortage of avail-
able mechanical ventilators are 3D printed splitters (class
II devices by FDA [58]), which allow the use of a single
mechanical ventilator by two different patients [15, 90]. Fur-
thermore, there are also open-source NIV helmets projects
like the Bubble Helmet from COSMIC Medical [91] that
may use 3D printed valves as ports for the assembly.
Venturi valves (Fig. 4b) operate by Bernoulli’s principle
of jet gas mixing [11] and can deliver a fixed fraction of
inspired oxygen (FiO2) [69, 87], depending on the valve
geometry [87]. They are used with a mechanical ventila-
tor and a Venturi mask during NIV procedures [11, 87].
They are also described as part of the CPAP system when
connected to a mechanical ventilator [12]. Therefore, these
valves are essential during COVID-19 pandemic because of
the high demand for respiratory devices. In Brescia, Italy,
a supply chain disruption made these valves scarce. Again,
ISINNOVA 3D printed by FFF Venturi valves in a short
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Fig. 4  a ISINNOVA’s Charlotte valve [51] made by different pro-
cesses and materials—from left to right: MJF/PA12, FDM/PC and
SLS/PA12. b Venturi valve models by SLS/PA12 and PolyJet/Vero-
Clear®. c Snorkeling mask connected to an ISINNOVA’s valve for
period of time, based on reverse engineering, and have saved
lives [52]. These valves were also further produced in SLS
and SLA [52]. Filip Kober further created 3D models to be
printed in SLA, downloadable at GrabCAD [92]. SLA is the
technique of choice because part porosity may alter the func-
tionality of the valves, changing delivered FiO2 [15]. The
models were simulated using computational fluid dynamics
(CFD) to ensure the correct values of FiO2 [52].
5.3 Isolation chambers and wards
A measure to prevent the SARS-CoV-2 dissemination is the
isolation of suspected or confirmed patients. As explored
before, patients in hospitals may spread the virus through
aerosols and droplets [4, 14]. Therefore, some devices can
reduce environment contamination. Cubillos et  al. [93]
developed a negative air flow isolation chamber for COVID-
19 patients. Their device consists in a rigid cubic frame
chamber draped with a clear plastic bag in which a continu-
ous negative air flow prevents air from inside the chamber
from contaminating the external environment. It uses 3D
being used during CPAP procedure. d Diverse types of valves:
1—Charlotte [51]; 2—Dave [51]; 3,4,5—Modified Charlottes; 6–
adaptors made by SLS/PA12
printed ports that allows suction, oxygen delivery and nebu-
lization. The instructions and plans are available under a
Creative Commons License, Attribution-NonCommercial-
ShareAlike 4.0 International. A collaboration of Sector 67
with University of Wisconsin-Madison Department of Sur-
gery, Dr. Hau Le, and UW-Madison College of Engineer-
ing [94] developed a negative pressure isolation head box,
named as “badger box”, which uses AM to produce glove
grommets. Another example of isolation chambers, although
more simplistic, were produced in Texas A&M University
[95]. The chambers work as a physical barrier for contami-
nated patients and consist in CNC cut vinyl and 3D printed
parts.
In large-scale projects, the creation of 3D printed isola-
tion wards by the Chinese company WinSun can be high-
lighted [96, 97]. The wards are used as a professional and
comfortable environment for patient isolation and treatment.
They can also serve as a properly sanitized and protected
resting place for healthcare professionals working directly
to combat the pandemic. The standard model is 10 ­m2 and
2.8 m tall. The 3D printed wards construction process is
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automated, resulting in low labor cost and rapid construc-
tion. The buildings can be moved to different locations and
can be easily connected to a power supply network [13, 34].
Finally, build process uses as feedstock material industrial or
solid construction waste and, after demolition, can be reused
in new 3D printed buildings [96].
5.4 Field respirators
An alliance between the Consorci de la Zona Franca de
Barcelona, HP, CatSalut and Leitat Technological Center
developed a field respirator, named as LEITAT 1, using AM
for prototyping and parts production. The device, a mechani-
cal bag valve mask, is to be used for short term emergency
ventilation. The emergency ventilator, tested in ICU patients
and approved by the Spanish Medicines Agency, has parts
produced by MJF and is industrially scalable [98, 99]. More-
over, Petsiuk et al. [100] designed an automated fully open
source bag valve mask-based ventilator, which also serve
as a temporary emergency ventilator. In their work, they
give a detailed protocol and links to the downloadable files,
which include 3D printable parts of the ventilator assembly.
The reported results exceed human capabilities in bag valve
mask-based manual ventilation.
5.5 Nasopharyngeal swabs
Massive testing is an important measure for fighting the
COVID-19 pandemic. For this, specimens from the upper
respiratory tract must be collected and tested by reverse tran-
scription polymerase chain reaction (RT-PCR) [10]. In this
sense, nasopharyngeal swabs provide the highest sensitivity
for the virus detection [50]. These are FDA Class I medical
devices [58] with a rod-shape and a head coated with short
synthetic filaments or spun fiber, used to collect secretions
from the upper respiratory tract from the patient. The swab
usually has a breakpoint on the shaft for enabling the head
storage in a vial with viral transport media. Then, the sealed
vial is sent for testing. To ensure a safe and reliable test, the
swab must be flexible and sterilizable [15, 101]. Cotton head
swabs are not indicated for COVID-19 [10, 50].
Cox and Koepsell [29] created a FFF printable and steri-
lizable PETG nasopharyngeal swab. They made clinical
tests using commercial swabs as control and found the 3D
printed model has the same efficiency of the control group.
Callahan et al. [50] made a multi-step preclinical evaluation
on 160 designs and 48 materials of test swabs and validated
4 prototypes. From this study, a consortium including Car-
bon, FormLabs, Envisiontec, Origin and Abiogenix com-
panies was created and can produce up to 4 million FDA
registered test swabs per-week via vat photopolymerization
with medical grade resin [102]. In the same work, swabs
designed for MJF medical grade nylon were also validated
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Progress in Additive Manufacturing (2021) 6:19–37
[103]. Arnold et al. [101] developed a swab with an open
lattice design to be produced by DLP process. The model
was tested and obtained a 90% match of results taking com-
mercial swabs as golden standard, showing the design is
adequate for test. Ford et al. [104] designed and developed
over 20 nasopharyngeal tips. Their final design showed a
94% concurrence with the current synthetic version in an ini-
tial study and multisite clinical trials are currently underway.
The STL models from the previous works are only available
by request to the companies.
Finally, some nasopharyngeal swabs designs can be found
at file repositories, such as the model from Fig. 5, designed
by MarianneE (Johns Hopkins University Applied Physics
Laboratory) user in the NIH 3D Print Exchange repository
[105]. This design is for production using SLS/PA12. How-
ever, it is important to remark that there is no evidence these
items have undergone any clinical test or validation, and the
manufacturers should be certified by ISO 13485 (Medical
Devices Quality Management System) for ensuring safe and
reliable tests.
5.6 Hands‑free tools
The COVID-19 virus may remain on different surfaces for
periods up to 72 h [5]. Thus, avoiding direct contact with
surfaces is an important way to reduce contamination during
the pandemic, especially in public and medical centers [15].
Some objects such as buttons, door handlers, switches etc.
are potentially virus spreaders because of the high number
of interactions with different people [36].
As a solution for reducing direct hand contact, various
hands-free tools were designed. François et al. [36] designed
and produced by FFF a high volume of various hands-free
tools to be used in Greater Paris University Hospitals and
other sites.
Fig. 5  Nasopharyngeal swab from MarianneE user from NIH 3D
Print Exchange repository [105] made by SLS/PA12. This design has
not undergone any validation process and is exhibited only as exam-
ple
Progress in Additive Manufacturing (2021) 6:19–37 27
Hands-free door openers are devices that are fixed to door
handles and allow door opening and closing with elbows or
forearms [36]. Materialise company designed different types
of hands-free door openers for cylindrical, rectangular, cir-
cular, and spherical handlers that can be 3D printed by MJF,
SLS or FFF technologies [46]. Figure 6a and b show Materi-
alise’s rectangular and circular hands-free door openers, and
the rectangular model usage. Furthermore, hands-free tools
for opening doors, pushing buttons, hooking handles, open-
ing water taps, and other daily tasks were created by various
designers for personal use. These hands-free designs can be
found in various repositories websites such as Thingiverse
[39], NIH 3D Print Exchange [40] and others. Figure 6c
and d shows hands-free tools by SimonSolar2C [106] and
bgiovanny [107] users from Thingiverse repository and an
example of use.
5.7 Antimicrobial devices
One major drawback of using AM polymers in some appli-
cations, such as masks, valves, and no-contact tools, is that
SARS-CoV-2 presents a high stability (up to 72 h) on these
surfaces. On the other hand, the virus stability on copper
surfaces are reduced to 4 h, as found by van Doremalen
et al. [5]. The previous work is in accordance with litera-
ture related to the use of some metallic coatings or nano-
particles into polymers. Some metals such as copper and
silver have antimicrobial characteristics and can be used in
the development of bioactive polymers [108]. Borkow et al.
[109] showed that a face mask doped with copper and cop-
per oxide particles reduce the risk of influenza (H1N1 and
H9N2) contamination.
Fig. 6  Hands-free models made
using SLS/PA12. a Material-
ise’s hands-free circular and
rectangular door openers [46].
b Rectangular model usage. c
Hands-free tools from Simon-
Solar2C [106] and bgiovanny
[107] users from Thingiverse
repository. d Tool being used
for opening door
In this context, Copper 3D company uses the antiviral
properties of copper to produce a face mask (named as
NanoHack) using the company’s bioactive materials PLAC-
TIVE® and MDflex®. The filtering system still require non-
printed material (non-woven polypropylene embedded in
copper nanoparticles) [110].
Another approach for antimicrobial devices is using anti-
microbial coatings on surfaces to reduce biofilm formation.
Muro-Fraguas et al. [111] used plasma-polymerization to
create an acrylic acid (AcAc) coating on 3D printed PLA
Petri dishes and obtained antibacterial properties using dif-
ferent Pseudomonas aeruginosa and Staphylococcus aureus
strains.
5.8 Training and education
One of the various applications for AM is the education
area. It can be used from printing simple forms to help chil-
dren to develop abilities and skills [112, 113] to adults and
professionals, where complex replicas to improve diagno-
sis, surgical planning and patient education can be printed
[113, 114]. In this regard, AuMed [115] designed a mani-
kin to help training of inexperienced healthcare workers in
COVID-19 diagnosis by nasopharyngeal swab testing. In
the education context, according to Hervás-Gómez et al.
[113], the use of AM in education is growing, following
the development of the Industry 4.0. Moreno Martínez and
Morales Cevallos [116] point out the opportunity to use the
AM notoriety during the COVID-19 pandemic to use this
technology to improve students interest, participation and
proactivity in experimentation and manipulation. The use
of 3D printed tactile models can also be a tool for commu-
nication with individuals who are visually impaired [112].
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28
Figure 7 presents two visual-tactile models of the SARS-
CoV-2 morphology. Both models explore the proteins, lipid
membrane and RNA from the virus. The models shown in
Fig. 7a and b also contain support bases with Braille tran-
scription for people who are visually impaired. Finally,
because of the rapid shift to online education that occurred
in various countries, simple solutions, such as 3D printed
mounts to point webcams downwards, may help instructors
to present a board-based pedagogical method [117].
5.9 Mask manufacturing tools
In a document with advice on the uses of masks during the
pandemic [59], the WHO guided governments to encourage
the general public to wear face masks. Because of the short-
age of surgical and N95 masks, homemade fabric masks
emerged as an interim solution. Consequently, some people
started to sew their own fabric masks and, in some cases,
Fig. 7  Visual and tactile educative models of SARS-CoV-2, showing
RNA, proteins, and lipid membrane. a SLS/PA12 model with base
containing braille writing and b PolyJet/VeroClear® + TangoBlack-
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Progress in Additive Manufacturing (2021) 6:19–37
to sell or donate these items. As a way for helping people
to increase the production of these wearables, 3D print-
able mask pleaters and bias tape makers were designed and
made available for download at diverse repositories, such
as Thingiverse [39]. Bias tape makers are folders that assist
the fabrication of cloth bias tape, as shown in Fig. 8, used
in finishing edges of fabric masks. Mask pleaters help the
production of pleated face masks. Both are time-consuming
tasks, and these simple designs act as tools for increasing
production.
5.10 Endoscopic procedure mask
The risks to health workers associated with aerosols and
droplets during IMV procedures were discussed in Sect. 5.2.
However, there are other medical procedures, like endo-
scopic skull base surgery, that also create high risks of
pathogens transmission. In this context, Helman et al. [55]
Plus® two-halves model. Models from own authorship and available
by request to the main author
Progress in Additive Manufacturing (2021) 6:19–37 29
Fig. 8  a Bias tape maker made
by SLS/PA12 used for b fold-
ing cloth. Model designed by
ongaroo user from Thingiverse
repository [118]
developed a 3D printed mask for endoscopic skull base sur-
gery. They redesigned the mask edge circumference from
open-source mask models and added an inlet and outlet to
the sides of the masks for tubing. Then, they used a surgi-
cal glove to provide a flexible physical barrier that allows
usage of medical instrumentation. They performed various
tests in two cadaveric models and found the device offers the
surgeon appropriate surgical degrees of freedom, maneuver-
ability and reduces risks of contamination. The mask model
is available by request to the main author of the work.
5.11 Metallic devices
As explored in Sect. 5.7, the COVID-19 virus stability on
copper surface is up to only 4 h [5]. Following these find-
ings, ExOne company and the University of Pittsburgh
worked in collaboration to develop sterilizable copper fil-
ters made by binder jetting technology. They use the pro-
cess intrinsic porosity after sintering to produce filters with
specific porosity levels to meet N95 filtration standard. One
major advantage of the filter is that it is reusable, reducing
waste disposal [119].
To summarize the data from all the 3D printed devices
presented in the previous sections to fight against COVID-
19 pandemic, Table 1 gathers information about used AM
technologies and their respective references.
6 Drawbacks
As AM has assumed an important role during COVID-19
pandemic, there are some major drawbacks that must be
discussed.
Different parts produced from a same STL file may
present significant variations in geometry and mechanical
properties because there are differences in material type
and quality, software, calibration and equipment [24, 28].
In a work by Mueller et al. [28], the authors raise several
questions about the material selection and quality control of
3D printed parts for COVID-19 pandemic. Most of medical
devices must comply with strict standards to ensure a safe
and reliable use, avoiding any preventable harm for patients
and professionals. As an example, FFF filament may retain
moisture, which could act as a virus transmitter during use or
reuse [24]. In addition, 3D printed parts have different char-
acteristics from parts produced by conventional methods:
the layer upon layer process may generate poor interfaces,
delamination, and unintentional porosity [122]. Thus, as
pointed by Larrañeta, Dominguez-Robles and Lamprou [14],
these parts may not provide the same security levels. In a
preprinted work from Bezek et al. [78], face masks produced
by FFF presented defects that decreased their efficiency in
filtering particles. Novak and Loy [57] indicate the need for
design for additive manufacturing (DfAM), which consid-
ers the AM process characteristics and particularities during
project. Therefore, makers must be aware of optimized print-
ing parameters for the application and the required quality
of each printed part [123].
In addition, since there is no review process for any STL
file uploaded in file repositories, there is no assurance that
the final models will be functional. Another issue is the high
number of different types of projects that can be found for
a same device, such as face-shields and face masks. As an
example, Novak and Loy [57] studied the manufacturability
of 37 and 31 different face-shield and face mask models,
respectively, from companies, groups, and individuals. They
found large differences in terms of cost and manufactur-
ing time between the models. This may be a concern when
choosing which model to produce. Another issue is choosing
valid models that were previously tested and reviewed by
medical workers, since there are various designs that lack
this information. In this regard, companies and scientific
papers are a better source of projects that were generally
developed by multidisciplinary teams and went through a
validation process.
With regards to issues, the regulatory agencies and
intellectual property are two relevant topics. Beyond
medical review and validation, medical devices must be
approved by the country’s regulatory agency, such as FDA
for USA, the Medicines and Healthcare products Regula-
tory Agency (MHRA) for the United Kingdom and the
Brazilian Health Regulatory Agency (Anvisa) for Brazil.
Hence, it is worth to say that every single person involved
in the production of medical devices must be aware of
his/her legal responsibility even as a philanthropic action.
Usually, the process for approval by a regulatory agency is
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30 Progress in Additive Manufacturing (2021) 6:19–37

Table 1  3D printed parts Item AM technologies References/Sources

produced during COVID-19
pandemic Face shields FFF, SLA, SLS [53, 62, 63]
Safety goggles FFF, SLA, SLS [65–68]
N95 respirators similar FFF [49, 71, 72]
Half-face masks FFF, MJF, SLS [38, 77, 79, 80]
Antimicrobial mask FFF [110]
PAPR parts FFF [74–76]
Ear Savers FFF [81]
Mask fitters FFF [82]
Isolation chambers FFF [93–95]
Isolation wards Not specified [97]
Valves for CPAP FFF [51]
Splitter valves Not specified [90, 120]
Valves for NIV helmets Not specified [91]
Venturi valves FFF, SLA, SLS [92]
Field Respirators parts Not specified [98, 100]
Nasopharyngeal swabs DLP, FFF, MJF, SLS, SLA [29, 101–105]
Hands-free door openers MJF, FFF, SLS [46]
Hands-free tools FFF [106, 107]
Manikin for swab testing training Not specified [115]
Educational models SLS, PolyJet Own authorship
Mounts to point webcams downward FFF [117]
Bias tape makers FFF [118]
Mask pleaters FFF [121]
Copper filters Binder jetting [119]
Surgery mask FFF [55]

expensive and requires considerable time [23]. Regarding
this, during the pandemic, some agencies had published
official declarations on the use of unapproved medical
products during the emergency [124, 125]. Previous to
the pandemic, in December 2017, FDA had published a
guidance with technical considerations for additive manu-
factured medical devices [126]. However, Pecchia et al.
[18] point that emergency situations demand universal
regulations, mainly for low- and mid-income countries.
Further, the authors also argue about the importance of
regulations and standards for guiding the manufacturers
for ensuring high safety levels, since even small defects
may harm the user. For the intellectual property theme,
most of the medical equipment from the existing medical
system is based on patented equipment from medical sup-
pliers [31]. Regarding this, Tino et al. [15] alert for the
reverse-engineering process and its possible legal issues.
They point that goodwill from regulators, legal experts,
and governments are essential for saving lives during an
emergency such as the COVID-19 pandemic. As an exam-
ple, ISINNOVA company rapidly patented their Charlotte
valve to prevent any price speculation and left it free to
use [51]. Furthermore, Mahr and Dickel [127] discuss how
the COVID-19 pandemic rapidly changed our thinking on
intellectual property and highlight the need for regulators,
ethicists, lawyers, and members of the industry community
to discuss and create guidelines for the maker community
during global crisis scenarios.
Finally, as shown by the current study and summarized
in Table 1, majority of parts and projects are developed
in polymer AM. Larrañeta, Dominguez-Robles and Lam-
prou [14] pointed FFF, SLS and SLA as the main AM
techniques used for producing COVID-19-related parts.
Besides, Novak and Loy [23] studied the AM projects
availability and also found that FFF, SLA, MJF, SLS and
other polymer-based techniques are the flagship AM pro-
cesses during the pandemic. Beyond polymers, AM can
work with metals, ceramics, and composites. In 2017,
the unit sales for metal AM systems grew by 79.9%,
well above the 12.6% growth of unit sales of overall AM
industrial system [21]. However, even with an exponen-
tial growth, metallic AM solutions during COVID-19 pan-
demic are almost zero. This statement could be related to
the high costs of metal AM machines and feedstocks, lead-
ing to a low number of disponible workforce. Thus, metal
AM fully potential was not explored during the pandemic.

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Progress in Additive Manufacturing (2021) 6:19–37 31
7 Potential uses of AM in future pandemics
In the history of mankind there are records of several pandem-
ics such as smallpox, cholera, Black Death (plague), AIDS,
influenza, SARS, West Nile disease and tuberculosis [128].
The “Spanish flu” influenza pandemic, the most lethal pan-
demic in recent history, killed more than 20 million people
worldwide [128, 129]. Influenza A (H1N1), a more recent
pandemic, occurred in 2009 and contaminated over 1.6 mil-
lion people and had 18,449 confirmed deaths [130]. In a more
localized spread, Ebola outbreak in West Africa in 2014–2015
resulted in 28,600 cases, resulting in 11,350 deaths, though it is
estimated that up to 70% of cases may not have been accounted
[131]. Even though infectious diseases have always plagued
humanity, during the last decade, there has been a significant
increase in the number of emerging and reemerging infections,
reaching more than 20 infectious agents [132]. In fact, since
1980 the number of infectious diseases has increased by nearly
fourfold because of the population growth, increased number
of domesticated species, and globalized economy—with an
increased people mobility [133]. Therefore, there is no reason
in expecting COVID-19 pandemic will be the last, or it will
take a long time for a new outbreak.
In this regard, beyond the already developed applications
for AM during emergency situations, there might be new
uses that will come from the technology advancements. As
explored previously, AM is a relatively recent technology, hav-
ing its first commercial system dated from 1987. The technol-
ogy has currently attracted attention from research and indus-
try, with new technologies and materials coming up daily. The
next sections show and discuss some specific AM fields that
may affect possible future applications for AM during future
pandemics.
7.1 New materials
New material development will make AM more competitive
toward conventional production technologies as it will create
opportunities to new design freedoms and applications [26].
As a previously discussed example, bioactive materials, such
as bioactive plastics, which present antimicrobial properties
[108–110], are still being developed and will reach common
public, opening a window for mass fabrication of bioactive
devices, such as valves, hands-free tool and masks. Regard-
ing this, Zuniga e Cortes [134] highlight the importance of
developing these materials as they may be an important tool
for fighting off the COVID-19 and future pandemics.
7.2 Metal and ceramic additive manufacturing
As reported, metal and ceramic AM did not show significant
engagement during the COVID-19 pandemic. Even though
metal AM has grown exponentially in the last years [21], it
is still an expensive technology with less facilities around the
world. However, this growth will create new opportunities
for the technology expansion, development, and accessibil-
ity, making it an important tool for possible next pandemics.
7.3 Design for additive manufacturing
The advantages of AM, such as freedom of design, allow
using lattice structures, organic shapes, stacking, cooling
channels, topology-optimized geometries and more. These
features are related to AM-engineering design, named as
design for additive manufacturing. The DfAM also relates
to process particularities, such as layer-by-layer manufactur-
ing, thermal history, and residual stress [135]. This area is
quickly evolving, aided by software development, and will
strongly impact AM industry and development. In a review
work, Thompson et al. [135] study the importance of DfAM
and highlight that the future will bring educational materi-
als for institutions, industry and hobby community. Conse-
quently, DfAM will evolve and leverage AM productivity,
suitability of design, lower production costs, and open new
opportunities of applications.
7.4 Rapid tooling
AM is a powerful tool for prototyping and small batch pro-
duction. However, when dealing with big batches, conven-
tional techniques, such as injection molding, are economic
favorable [136–138]. As an example, a preprinted work
by Kunkel et al. [139] presented a qualitative comparison
between AM and injection molding capabilities for large-
scale production of face shields. For a single AM machine,
the production capability was of about 10 per day, while
for an injection molding machine it reached a capability of
2000. Nevertheless, AM can be used for rapid tooling, an
accelerated production of tools for injection molding. Fur-
thermore, conformal cooling channels can be added in the
design. Conformal cooling channels, which cannot be pro-
duced by conventional production technologies, are cooling
channels in tooling that follow the shape of the designed
parts. These channels provide enhanced thermal control
with improved heat exchange, implying in faster produc-
tion cycles, better products, and increased injection tool life
[69, 135, 136, 140]. This area is related to the DfAM field
and is developing as research is done [135]. Therefore, AM
will be able to accelerate the production of tooling devices
for optimized mass production. As an example made reality
during the pandemic, to achieve mass production, Catalysis
Additive Tooling company took 2 weeks to design and pro-
duce a 3D printed metallic injection mold for manufacturing
headbands for face shields [141].
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32
7.5 Bioprinting
A technology with great potential to help fight pandemic
diseases is bioprinting. This is a technology, emerged from
3D printing in 2003 [142], that uses bioink as deposition
material [143]. Groll et al. [144] define bioink as “a formu-
lation of cells suitable for processing by an automated bio-
fabrication technology that may also contain biologically
active components and biomaterials”. Still in its infancy,
the technology can be used in regenerative medicine to
support the manufacture of tissues and organs for trans-
plantation [145, 146]. It could also be used for producing
lung models—or any other organ model -, which could be
used to study a disease dynamic and analyze an infected
organ response to drug targets, detecting the disease pro-
gression in vitro [147, 148]. In this regard, Berg et al.
[148] have shown the model ability to mimic the distribu-
tion of an influenza A virus strain in a real lung, something
impossible for traditional cell culture.
7.6 3D printed medicines
As the pandemic diseases can easily overpass frontiers,
it is important to develop strategies for producing and
distributing drugs to all parts of the world during supply
chain disruptions. Regarding this, there is the possibility
to 3D print oral solid dosage forms (OSDF) with differ-
ent drugs in a customized way [140, 149]. These medi-
cines can be produced with controlled dosages, according
to patients’ characteristics, with controlled release and,
most importantly in a pandemic scenario, in a decentral-
ized way [140]. Therefore, AM can be used for producing
drugs at hot spots where conventional drugs cannot reach
[140]. However, quality control, costs lowering, and the
selection of the AM technology according to the formula-
tion requirements are some key challenges that must be
addressed for this application to be viable possible future
pandemic scenarios [140].
7.7 Industry 4.0
The AM technology is described as part of Industry 4.0 [28,
113]. Regarding this, Choong et al. [34] highlights that AM
machines will continue to be key parts in the cyber-physical
post-pandemic scenario. In a review by Khan and Javaid
[150], the authors point AM machines as part of an auto-
mated emergency system composed by innovative technolo-
gies, such as drones, machine learning, and artificial intel-
ligence, to quickly deliver PPE at required places without
human contact. Therefore, AM will benefit from Industry
4.0 development.
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Progress in Additive Manufacturing (2021) 6:19–37
8 Final considerations
Additive manufacturing has emerged as an essential tech-
nology during COVID-19 pandemic. Because of the sup-
ply chain disruption, various devices, such as face shields,
face masks, valves, nasopharyngeal swabs, and other
devices were in shortage. Quick and innovative design
associated with AM were successfully used for production
of these items, saving lives from health workers, patients,
and general population. These devices could be almost
instantaneously produced in diverse parts of the world, as
soon a project file was projected or shared through global
network, pointing out for a future reduction in logistics
with local production. Other major features that lever-
aged AM role during pandemic were the great number of
3D printers spread around the world, even in developing
countries, the ease of sharing and downloading printable
parts, and its ability for rapid prototyping first designs and
equipment parts. Accompanied from diverse initiatives of
companies, groups, and individuals in helping people in
need, a mass production of devices was reached.
As this massive production gained the notoriety of
people and media, it also brought up some issues to be
overcome before the next emergency. The lack of central-
ized standards and guidelines from regulatory agencies
caused different people, groups, and companies to take
the initiative for producing non-validated parts from their
own experience. This issue called the need for producing
pre-approved guidelines for these situations that will allow
people to help in a short period of time, without being
threatened by legal issues and harming final users. Fur-
thermore, intellectual property emergency laws must be
developed to ensure people lives, as during the pandemic
the supply chain disruption created a shortage of diverse
essential devices from medical suppliers. In this line,
public domain open-source equipment and devices can be
developed and act as an emergency option during these
situations. Within that, scientists must work in testing and
publishing results. These works will remain in literature
as a reliable peer-reviewed data, beyond media and social
media volatile information, and will help the development
of guidelines and projects that may be centralized and stay
as resource during future pandemics.
Finally, AM is still a relatively recent technology. Mate-
rials, techniques, software, and applications are being
developed daily. This will ensure that additive manufac-
turing will continue to be fundamental to help humanity
fight the next coming pandemics.
Author contributions  GAL: main idea; literature search; data analysis;
draft; critical review. GBN: literature search; draft; critical review. GC:
critical review. JVLS: literature search; draft; critical review.
Progress in Additive Manufacturing (2021) 6:19–37 33
Funding  This study was funded by the National Council for Scientific
and Technological Development (CNPq), Grants nos. 139963/2019-7,
301626/2020-0, and 301624/2020-8 and the Scientific Research Foun-
dation for the State of São Paulo (FAPESP), Grant no. 2020/05612-8.
Availability of data and materials  Not applicable.
Compliance with ethical standards  Med Public Heal 6:76. https​://doi.org/10.5455/ajpmp​h.20200​
Conflicts of interest  The authors declare that they have no conflict of
interest.
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